Surgical Endoscopy Request a Rep

Practice Information:

Provider Type

Primary Specialty

Name of Practice or Organization

Zip Code of Practice or Organization

Personal Information:

First Name

Last Name

Email Address

Confirm Email Address

Phone Number

City

State/Province

Reason for Contacting an Endoscopy Representative:

My request is regarding:

Yes, I consent to Boston Scientific using all information I enter onto this form to contact me with information regarding its products and services, inform me regarding various news, events and research studies and allow Boston Scientific to use this information for additional purposes identified in its Privacy Policy and Terms of Use.

By submitting this form, I consent to Boston Scientific using the email or phone number I have provided to contact me regarding endoscopy procedures and products.  My submission also is my acceptance of, and consent to, the Boston Scientific Privacy Policy and Terms of Use.